Comprehensive Respiratory Requisition

Patient Information

Physician Iinformation

Clear Signature
Specimens will not be processed without a Health Care Provider's signature and ICD-10 code

Collection Information

Parent/Guardian Consent for ALL patients under 18 Y.O. to Receive Test Results via Text and / or Email

Race & Ethnicity

Billing Information (please attach copies of all cards, front and back)

Note: the following diagnosis codes are listed as a convenience only. Ordering physicians are REQUIRED to use the ICD-10 code that best describes the reason for performing the test, whether or not that code is listed below.

Specimen Submitted

• Campylobacter (jejuni, coli, and upsaliensis) • Clostridium difficile (toxin A/Bl • Plesiomonas shigelloides • Salmonella • Yersinia enterocolitica • Vibrio (parahaemolyticus, vulnificus, and cholerae) • Vibrio cholerae Diarrheagenic E. coli/Shigella • Enteroaggregative E. coli (EAEC) • Enteropathogenic E. coli (EPEC) • Entertoxigenic E. coli (ETEC) It/st • Shiga-like toxin·[Jroducing E. coli (STEC) six l / stx2 • E.coli0157 • Shigella/Enteroinvasive E. coli (EIEC)

• Cryptosporidium • Cyclospora cayetanensis • Entamoeba histolytica • Giardia lamblia

• Adenovirus F40 / 41 • Astrovi rus • Norovirus GI/GIi • Rotavirus A • Sapovirus (I, II, IV and V)

1. Fully complete requisition form witli all required information.
2. Complete specimen label with patients date of birth and full name.
3. Remove label and place bar coded label VERTICALLY on the specimen vial (not on the lid).

* Please ensure the patients date of birth and full name is indicated so that both the label and requisition match. Two patient identifiers are required on each specimen submitted. The unique barcode identifies the patient with this requisition form.